Provider Demographics
NPI:1639674021
Name:LIU, JENNY (OD)
Entity Type:Individual
Prefix:
First Name:JENNY
Middle Name:
Last Name:LIU
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 VIA DE LA VALLE
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92532-0138
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5200 E RAMON RD STE H2
Practice Address - Street 2:
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92264-3619
Practice Address - Country:US
Practice Address - Phone:213-505-4907
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-27
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33898TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist